INDIRECT CORONARY REIMPLANTATION IS ASSOCIATED WITH INCREASED OPERATIVE RISK IN PATIENTS UNDERGOING A BENTALL PROCEDURE AFTER PREVIOUS CARDIAC SURGERY

Abstract

We sought to evaluate the early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery. From 1990 to 2014, 473 patients underwent a redo Bentall procedure with a composite valve graft (CVG) at a single institution (CVG with a mechanical prosthesis, n = 256; CVG with a bioprosthesis, n = 217). The primary outcome was 30-day mortality. The secondary outcome was a composite of major morbidity and operative mortality (MMOM): stroke, renal failure, prolonged mechanical ventilation, deep sternal infection or reoperation during the same admission. Median age was 57 (IQR: 44 – 67) years and 349 (74%) patients were male. Median time between index surgery and reoperation was 13 (IQR: 8-21) years. One hundred seventy-eight (38%) patients underwent urgent or emergent intervention, 61 (13%) had active endocarditis, 87 (19%) had an LVEF < 40%, and 262 (55%) patients had undergone more than one previous operation. Previous surgery included CABG (n=58, 12%), aortic valve/root repair (n=36, 8%) or replacement (n=376, 80%), and other surgical interventions (n=245, 52%). Ninety-five (20%) patients had undergone coronary reimplantation during the previous operation, which consisted of a Bentall procedure in 80 patients, a Ross operation in 8, a valve-sparing root replacement in 4, and an arterial switch in 3. At the time of the reoperative Bentall, both coronaries were reimplanted directly in 352 (74%) patients, whereas 72 (15%) patients received at least one interposition graft (saphenous vein in 42, and synthetic in 30). In 32 (7%) patients, at least one of the native coronary arteries was oversewn and a vein graft bypass performed. Thirty-day mortality occurred in 37 patients (7.8%) and 152 (32%) patients suffered MMOM. On multivariable analysis, risk factors associated with increased 30-day mortality included older age (OR per 5-year age increment [95% CI]: 1.20 [1.04-1.38], p = 0.01) and coronary reimplantation by a technique other than direct anastomosis (OR 3.71 [1.76-7.87], p < 0.001). Indirect coronary reimplantation was also associated with a higher incidence of MMOM (OR 1.71 [1.05-2.77], p=0.03), as were older age (OR per 5-year age increment: 1.08 [1.01-1.17], p = 0.03), preoperative NYHA functional class IV (OR 3.44 [1.55-7.62], p=0.002), and more than one previous cardiac operation (OR 1.75 [1.11-2.76], p=0.02). In the largest reported cohort of aortic root replacement after previous cardiac surgery, reoperative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important predictor of adverse perioperative events.